We’re pretty open a
bout lessons learned. We share incident information with our research
ers and maintain a website of lessons learned from incidents at our
institution. We use them as case studies during lab safety training
and talk not just about the causes, but the choices made and behaviors exhi
bited in each incident.

The DOE has an excellent "lessons le
arned" program. There reports used to be available to the public, but
I think most now require a password/account to get to.
http://www.hss.energy.gov/csa/analysis/ll/
Kim Auletta
Lab Safety Specialist
EH&S Z=6200
Stony Brook University
kauletta**At_Symbol_Here**notes.cc.sunysb.edu
631-632-3032
FAX: 631-632-9683
EH&S Web site: http://www.stonybrook.edu/ehs/lab/

Frank Demer's database and that of the AIHA are terrific. Frank's stands ou
t to me because of the institutional support, while the AIHA database is 'a
nonymous'--you don't know where the incidents occurred.

While I don't doubt many institutions do have a 'what happened/how to preve
nt it' review, that knowledge often appears to be kept within the instituti
on. Whether this is for legal reasons, or the PR folks don't like to
have this information available, or another
reason, I don't know. And of course, from time to time C&E News
will print letters from researchers about an experiment that should have be
en standard, but wasn't. What is particularly helpful about a databas
e collated by EH&S is that you can see accidents
that occurred in biology, biochem, neuroscience labs, etc. These are
important chemical-use research areas where the researchers are not focuse
d on the chemical aspects and might be reluctant to go to a "Accidents
in Chemistry Labs" blog or even know about
C&E News.

The "we don't talk about it to outsiders" response has happened t
o me personally as I tried to follow up with a college in New England regar
ding a chemical fire that was reported via the news. It hit home beca
use a year or so earlier, they had contacted me
about an accident here. I shared my details with them and other coll
eges in our New England Small Colleges Association, precisely so a repeat i
ncident could be avoided elsewhere. Unfortunately their institution d
id not permit reciprocation. And I think
if you look at a number of these incidents, many which don't involve emplo
yees (and bring in OSHA) or which occur at private institutions (so no FOIA
requirements) are not shared with the community beyond what is first repor
ted in the news (and we know how
helpful THAT is at getting to the root cause!) And they should be, a
t least in a database that shields the institution, if desired.

My personal opinion only, not legal or business advice, and may not be the
opinion of my employer or any group to which I belong.
Margaret Rakas

>>> "Koza, Mary Beth (Environment Health & Safety)"
<MBKOZA**At_Symbol_Here**EHS.UNC.EDU> 6/29/2
011 11:20 AM >>>
Group,I take exception to suggesting that
serious academic institutional/departmental follow-u
p response is not a normal part of the accident review. Many academic
institutions have a process, consisting of root cause analysis
and lessons learned. Making such a broad statement is counterproduct
ive to the importance of safety.Mary Beth KozaDirector of EHS University of North Carolina - ChFrom: DCHAS-L Discussion List [mailto:DCHAS-L**At_Symbol_Here**list.uv
m.edu]
On Behalf Of ILPI
Sent: Tuesday, June 28, 2011 11:25 PM
To: DCHAS-L**At_Symbol_Here**LIST.UVM.EDU
Subject: Re: [DCHAS-L] Boston College incident follow up

I concur that realistic, repetitive training can go a long way to ameliorat
ing panic reactions in emergency situations. Alas, the resources and
institutional commitment for this sort of thing are lacking in most academi
c situations, and for some folks it just
won't ever sink in.

One low-cost method that may be effective is to place a site-specific poste
r-size emergency checklist in the most visible common area of the laborator
y/suite. Focus on the most important response issue (fire/explosion,
for example) only. Hopefully, the workers
in the area will better retain their key emergency response skills (or eve
ntually learn them through osmosis) or perhaps they may even turn to the po
ster in an emergency (911 called, fire alarm pulled, evacuation, personnel
accounted for etc. etc.). As a
small example of what I mean, see the fire checklist I have posted at
http://www.ilpi.com/safety/extinguishers.html#Using

I have never personally seen laboratory safety training materials discuss t
hat the trainee or his/her coworkers may freeze, panic, or do something com
pletely wrong in an emergency situation. A coworker's inappropriate r
eaction can not only be distracting or
disorienting, it can compound an already bad situation. I encourage
everyone to include this topic in their training courses.

Recent events (UCLA, Yale etc.) aside, I have never personally seen serious
academic institutional/departmental follow-up response with Lessons Learne
d from minor accidents, major incidents, or near misses. Having a pr
otocol for a formal analysis (What happened?
Facts instead of departmental gossip. What went wrong? How cou
ld this be avoided? What SOP's should change? etc.), ensuring that th
e analysis is distributed to all possible stakeholders, and archiving it on
an easily accessible web site is a great way of
making sure that history does not repeat itself. I have the impress
ion that this kind of analysis is the norm at places like DuPont, but, sadl
y, in my own personal experience, academic institutions often fail to do so
either out of liability/publicity concerns,
leadership inertia/vacuum, or both. Formal accident followup
s should be SOP and the importance of these should be stressed in academic
safety training courses.

Finally, those archived incidents make great case studies that should be ut
ilized in laboratory training. After giving the full spiel, take the
time to pull out a couple of case studies and ask the trainees what should
have been done, what could have been
improved etc. Interactive training forces the trainees to think abou
t the issues and the instructor achieves instant feedback on how effective
the training has been. This makes training a much more interesting ex
perience for both parties. If you are fortunate
enough not to have any site-specific cases to use, a wealth of them are av
ailable at
http://www.aiha.org/insideaiha/volunteergroups/labHandScommittee/Pages/Labo
ratorySafetyIncidents.aspx The unexpected dangers reported at
http://pubs.acs.org/c
en/safety/index.html also afford additional scenarios.

On Tuesday, June 28, 2011 David C. Finster said to the DCHAS-L Discussion
List in part:

I would "second" Brad's comments about the need for training
and education that exposes students to simulated events and
that is heavily based on repetition. Truth is: people panic
when confronted with unexpected events and, in knowing this,
it's almost laughable that one of first "rules" we teach in a
panic-inducing situation is "not to panic." Yeah, right. So
,
I tell students to go ahead and "panic" (for a BRIEF moment!)
to get that out of the way and then "go back to your
training".

Since panic is a visceral reaction that prevents reason and logical
thinking, it seems to me that telling people "not to panic," eith
er in
training or at the time of a frightening event, is one of the most useless<
br>
instructional activities imaginable. Repetitive simulated practice that
other have endorsed is the way to go. That is likely to prevent panic by
reducing the novelty of the situation.

"Don't panic" as an instructional step is on a par with "Be
more careful" in
counseling someone whose apparent lack of attention is thought to have
caused an "accident." Both phrases make the speaker fell better,
but neither
conveys actionable guidance.

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